Heat-not-burn tobacco products: a systematic literature review

OBJECTIVE: To review peer-reviewed evidence on heat-not-burn tobacco products (HnB), their secondhand emissions and use by humans; to identify differences between independent and industry-funded studies. DATA SOURCES: Medline, Embase, PsycINFO, ProQuest, Scopus and Web of Science databases were searched up to 6 November 2017 for studies on HnB published after December 2009; reference lists were screened and other researchers contacted, yielding 637 records. STUDY SELECTION: Thirty-one publications on HnB secondhand emissions (n=16) or use by humans (n=15) were selected by two reviewers with excellent agreement (k=0.75). DATA EXTRACTION: Data on authors’ affiliations, HnB products, secondhand emissions and human exposure were extracted by one reviewer. Two reviewers assessed the quality of experimental HnB studies using the Effective Public Health Practice Project tool. DATA SYNTHESIS: Twenty out of 31 studies were affiliated with tobacco industry. Studies on secondhand emissions varied by methodology, products and comparators. Compared with cigarettes, HnB delivered up to 83% of nicotine and reduced levels of harmful and potentially harmful toxicants by at least 62% and particulate matter by at least 75%. Experimental HnB use studies were limited to one product, reductions of human exposure to toxicants varied between 42% and 96%. HnB use suppressed urges to smoke, but participants rated HnB less satisfying than cigarettes. While limited by methodological heterogeneity, findings were largely similar for independent and industry-funded studies. CONCLUSIONS: Studies on HnB secondhand emissions and human use were heterogeneous and largely affiliated with the manufacturers. HnB exposed users and bystanders to toxicants, although at substantially lower levels than cigarettes.